Pregnant with cancer

Author: Laurie Wertich

Jackie Malena was seven months
pregnant when she was diagnosed
with stage II hepatocellular carcinoma
(HCC ). The uncomfortable pain she had
originally chalked up to pregnancy was
actually the result of a football-sized tumor
that was hanging off of her liver.
“Suddenly, I had a 2-pound baby girl and
a 2-pound tumor fighting for the same
space,” she explains.

At the time, HCC was considered
somewhat of a silent killer because by
the time it appeared on scans, it was
nearly impossible to treat. The only treatment
option was surgery. Suddenly, Jackie
was thrust into a flurry of decisions
she never expected to encounter. Should
she have surgery while she was pregnant,
or should she wait? The tumor
was growing quickly—was there time
to wait? How would surgery affect her
growing baby? If doctors had to make a
choice during surgery, who should they
save—her or the baby?

Jackie’s was a crash course in cancer
and its treatment. Just four days after the
diagnosis, she underwent groundbreaking
surgery that successfully removed
the tumor while keeping her baby in
utero. Two months later she delivered a
healthy baby girl.

Cancer and pregnancy

It seems like an impossible juxtaposition
that cancer and pregnancy can coexist,
but they can and they do. In fact,
about one pregnant woman in 1,000
is diagnosed with cancer each year in
the United States. That means approximately
3,500 women per year face the
most ironic twist of fate: their bodies are
fighting to grow new life in the midst of
an invasion of deadly cancer cells.
While cancer during pregnancy is
still considered rare, the incidence appears
to be on the rise—possibly because
more women are delaying childbirth until
they are older. In 2009 Swedish researchers
found that the incidence of
breast cancer diagnosed during pregnancy
more than doubled between 1963
and 2002, partly because of an older age
at conception.1

The most common cancers diagnosed
during pregnancy are breast cancer,
cervical cancer, lymphoma, and
melanoma. Interestingly, the cancer itself
rarely harms the baby, and some of
the treatments are even considered safe
for a growing fetus. Like Jackie, many
pregnant women experience the ultimate
happy ending: cancer survival and
motherhood.

Diagnosing cancer during pregnancy

Diagnosing cancer during pregnancy
can be tricky. On the one hand, pregnancy
sometimes serves as an opportunity
to uncover cancer because women
are undergoing more checkups and ultrasounds.
In fact, there is some evidence
that widespread use of ultrasound
during pregnancy has led to the detection
of asymptomatic ovarian cancer.2,3

On the other hand, pregnancy can often
serve to mask symptoms of cancer
because women either do not notice the
changes in their bodies or they mistakenly
attribute any new or unusual symptoms
to the pregnancy. Ironically, the
signs and the symptoms of breast cancer
can be similar to the changes in a woman’s
body during pregnancy.

Furthermore, women become singularly
focused during pregnancy—with
all attention on their growing baby. As
a result, they may be more hesitant to
address any other health concerns that
could affect the pregnancy. Any delay
in diagnosing cancer can be risky
because it gives the cancer time to grow
and spread. Early-stage cancer is always
more treatable than later-stage cancer.

Treating cancer during pregnancy

Cancer treatment for pregnant women
has come a long way in a short time. Historically,
doctors recommended terminating
the pregnancy to deliver the best
treatment and chance of a cure to the
mother. Now we know better.

Today physicians take a two-pronged
approach to treating pregnant women—
their goal is to treat the cancer while
protecting the baby. “Cancer during
pregnancy presents a challenging clinical
situation because the well-being
of the mother and the fetus need to be
taken into account,” explains Sagun
Shrestha, MD, a hematologist-oncologist
and medical oncologist at Cancer Treatment
Centers of America® (CTCA ) in
Tulsa, Oklahoma. “It is important to have
good communication between the obstetrician
and the oncologist, so all the care
is well coordinated,” Dr. Shrestha says.
I n most cases, physicians treat the
cancer in the same way they would if
the patient were not pregnant—with
some safeguards in place.

Safety and cancer treatment during pregnancy

It seems counterintuitive: women take
extra care during pregnancy to avoid
things like caffeine, alcohol, tobacco,
and even sushi, yet if they are diagnosed
with cancer, they may end up undergoing
chemotherapy. How can that be safe?
Though some drugs do have “blackbox
warnings” forbidding their use during
pregnancy because of their toxicity,
it turns out that certain types of chemotherapy
are considered safe during
pregnancy because the drug molecules
are too large to pass through the placenta
and are thereby prevented from
reaching the baby.

Despite the proven safety of these
drugs, delivering chemotherapy during
pregnancy can be tricky. Dr.
Shrestha explains, “There are certain
physiologic changes during pregnancy that change the way the body handles
the chemotherapy.”

Physicians take great care to deliver
the right chemotherapy at the right time
to offer the best treatment for the patient
while keeping the baby safe. “The
timing and the period of exposure to
chemotherapy is critical,” explains Dr.
Shrestha. “The greatest risk of congenital
abnormality is during the first trimester
of pregnancy.”

Often chemotherapy may not be directly
harmful to the growing fetus but
can be indirectly harmful as a result of
side effects experienced by the mother,
such as malnutrition or anemia.

In addition to chemotherapy, most
women can tolerate surgery well. The
bottom line is that with extra precautions
in place, pregnant women can be
successfully treated, carry their babies to
term, and give birth to healthy babies.

Delivering a healthy baby

Cancer may seem to steal the spotlight
from the pregnancy, but ultimately both
mother and doctor are always focused
on the health of the baby and plans for a
successful delivery.

Dr. Shrestha notes, “The timing of
delivery in relation to chemotherapy
administration should be carefully considered.
Delivery should occur following
a time when the mother’s white
blood count and platelet count are
within normal limits to prevent infections
and bleeding.”

Jackie’s pregnancy was just 27 weeks
along when the tumor was removed, and
she recounts the heroic efforts of doctors
to ensure that she did not go into labor
during or after surgery. “They staffed a
nurse to sit by my bed in the IC U,” she
recalls. “At any minute something could
go wrong, and they were dealing with
two people, not just one.”

Jackie spent two weeks in the hospital
before she was discharged. “I went home
with 30 staples down my pregnant belly
and with a very active baby who was
kicking a lot,” she remembers. Jackie recovered
from surgery, and her healthy,
7-pound daughter was born just three
weeks early.

From cancer to motherhood

It can be a shocking transition to endure
cancer treatment and then face
the challenges that come with motherhood.
“I had newborn trauma and cancer trauma,” Jackie recalls. “The surgery
took care of the cancer and then—
boom—I was a new mom. My whole
world changed when I became a mom.”

All new mothers are overwhelmed
and exhausted, but new moms who have
just survived cancer experience a unique
emotional journey: they face the same
exhaustion coupled with medical questions
and fears. “Late at night was when
I most feared the cancer’s coming back,”
Jackie admits.

In addition to the fear, these moms
may still have to cope with the very real
side effects of treatment. The things
most of us take for granted may not be
possible in the face of cancer. For example,
mothers who are still undergoing
treatment may have to forgo breastfeeding
because although cancer cells cannot
pass through breast milk, chemotherapy
drugs can.

Finally, even if initial treatment is effective,
women who are diagnosed with
cancer while they are pregnant must
continually monitor their health after
they give birth and, sometimes, must
manage the reality of a recurrence. In Jackie’s case, cancer recurred several
years after the initial diagnosis, at which
point she underwent treatment at CTCA
in Tulsa.

There is no doubt that cancer and
pregnancy are strange bedfellows, characterized
by the contrasts between
stress and joy, fear and elation. But this
once-impossible situation is now surmountable.
And, of course, surviving
cancer makes the joy of motherhood
even sweeter.

No case is typical. You should not expect to experience
these results.